NR-326 Mental Health Nursing - Set 5 - Part 1

Correct Answer: Ask the mother how he communicates and shows pain

The caregiver holds the individualised profile the team lacks: how this teenager communicates, what calms him, what sets him off and how he shows pain. That information shapes every interaction that follows. Option b is incorrect because being nonspeaking says nothing about swallowing ability. Assuming a physical deficit from a communication difference is a form of diagnostic overshadowing, and no finding here suggests dysphagia. Option c is incorrect because that tablet is very likely his voice. A communication device is never taken from a nonspeaking client, since removing it leaves him unable to report pain or ask for anything. Option d is incorrect because separating this teenager from the one person who reads his cues raises anxiety and strips the team of its best resource. Keeping the caregiver present is a stated nursing adaptation.

Correct Answer: Treat the burn and address food and rest

Crisis work stalls when the body is failing. Physical needs come first, so the nurse tends the burn, gets food and fluids in, and arranges rest before any problem solving can realistically begin. Option a is incorrect because planning a place to live asks a starved, sleepless, intoxicated man to make decisions he cannot hold onto. Housing matters, but it belongs after the body has been stabilised. Option b is incorrect because breathing exercises are useful once someone can attend to instruction. Alcohol on board and three days without sleep leave nothing to work with, and the untreated wound still needs care. Option c is incorrect because exploring meaning is a middle stage task in crisis intervention. A burn that nobody has looked at outranks insight, and Maslow puts the physiological emergency at the front of the queue.

Correct Answer: Assess vital signs and examine the abdomen

A new or changed symptom gets a physical assessment every time. Somatic symptom disorder does not protect anyone from appendicitis, and assuming a psychological cause is how genuine surgical illness gets missed. Option b is incorrect because labelling this as the familiar pain skips the very data that would separate the two. Guarding and fever are objective findings her long standing complaint has never carried. Option c is incorrect because scheduled visits structure routine symptom reports, not acute events. Delaying evaluation of a rigid, febrile abdomen for the sake of a behavioural plan puts the client in real danger. Option d is incorrect because charting alone records the complaint without evaluating it. Documentation follows assessment rather than replacing it, and filing this under chronic pain would delay recognition of a possible surgical abdomen.

Correct Answer: "I have a code word my sister knows to call for help."

A code word lets her signal for help without saying anything he would recognise. It is a core piece of the plan, along with a hidden bag, a route out, and a destination. Option a is incorrect because a bag stored in a shared closet is a bag he can find. The point of hiding it elsewhere, or with a trusted friend, is that discovery itself provokes an assault. Option b is incorrect because standing her ground during an escalation raises her risk rather than lowering it. Safety planning teaches exit and concealment, never confrontation with someone who is already violent. Option d is incorrect because kitchens and bathrooms are the rooms to avoid during an argument. One holds obvious weapons and hard surfaces, the other has no second exit, and both trap her.

Correct Answer: Cloudy, foul smelling urine and a fever

Urinary tract infection is the classic precipitant of sudden confusion in older adults, and cloudy foul urine with fever points straight at it. Treating the infection typically returns the client toward her previous baseline. Option b is incorrect because a small change on a cognitive tool tracks the decline already known about and offers no physiologic explanation. It cannot account for new unsteadiness or fresh incontinence appearing within a day. Option c is incorrect because steady weight is a reassuring finding rather than a trigger. Nutrition and hydration problems do drive confusion, but that happens when intake drops sharply, which this stable measurement rules out. Option d is incorrect because hearing loss present for years cannot explain a change that began yesterday. Uncorrected sensory input does worsen misperception, so the aid belongs in the plan, yet it is not the precipitant.

Correct Answer: Interview the client alone about his home care

Nothing can be assessed while the person who controls his money speaks for him. Interviewing him alone allows capacity, safety, and the financial changes to be explored before any report is made. Option a is incorrect because the explanation would come from the very person under suspicion. Questioning him also alerts him, and a suspected abuser who feels exposed may block further contact with the client. Option b is incorrect because a night of waiting adds nothing to a picture that already includes neglect and possible financial exploitation. Charting is necessary but it protects no one by itself. Option c is incorrect because announcing a report to a family member is confrontation, which the nurse avoids. The client is told what must be reported and why, unless telling him would place him in danger.

Correct Answer: Turn on lights before dusk arrives

Sundowning worsens as light drops and shadows spread, so brightening the unit before dusk removes the misperceptions that feed the agitation. Quiet, familiar surroundings afterward keep the evening from escalating further. Option a is incorrect because bathing demands undressing, cold, and close contact at the hour when tolerance is lowest. Demanding personal care belongs in the morning, when the client is better rested and able to cooperate. Option b is incorrect because a long late nap fragments night sleep and deepens the circadian disruption already driving the confusion. Short rest earlier in the day serves the client far better than an extended afternoon sleep. Option d is incorrect because noisy programming adds stimulation to a brain already overloaded by fatigue. Evening care aims at lowering input, so television, alarms, and busy hallways all push agitation upward rather than settling it.

Correct Answer: Offer an oral medication he may accept

The ladder moves from talking to a voluntary medication before anything is done against his will. Offering the dose as a choice keeps some control with him and often prevents the next rung entirely. Option b is incorrect because restraint is the last rung, justified only by imminent danger once everything gentler has failed. He is threatening and striking a wall, and an untried medication offer still sits between him and the bed. Option c is incorrect because words have already stopped working, and staying in front of an escalating man who is hitting things puts the nurse in reach. Repetition past that point is persistence, not de-escalation. Option d is incorrect because locking someone alone in a room is as restrictive as tying him down, and the same last resort standard applies. Convenience for staff is explicitly not a lawful reason to seclude.

Correct Answer: "That is upsetting. Let us look for it together."

Naming the feeling and offering to search together answers the distress without arguing about the accusation or agreeing with it. Helping look preserves dignity and usually ends with the purse found and the fear settled. Option a is incorrect because a blanket denial defends the staff and dismisses what the client feels. Reassurance offered this way rarely persuades anyone who is frightened, and the accusation typically returns within the hour. Option b is incorrect because correcting the facts contradicts a belief she cannot revise. She will not retain the correction, though she will remember feeling challenged, and that humiliation often sparks a larger outburst. Option c is incorrect because a why question demands abstract reasoning that dementia has already taken away. Being asked to justify the belief raises anxiety and pushes her to defend the accusation more firmly than before.

Correct Answer: "We work for a few weeks, restoring how you functioned before."

Crisis work is short term, typically four to six weeks, and aims to return the client to the functioning she had before the marriage ended, sometimes to a stronger level. Personality change is not the target. Option a is incorrect because restructuring personality is the work of long term psychotherapy. Crisis intervention deliberately stays with the present problem and closes within weeks, so promising years of treatment misrepresents what she has been offered. Option b is incorrect because digging into early life history belongs to insight oriented therapy. The crisis nurse keeps the focus on the here and now, on what happened this month and what will help tomorrow. Option d is incorrect because sadness may well outlast the counselling, and erasing feeling was never the goal. Crisis carries both danger and the chance to grow, and success is measured by restored functioning rather than absent distress.

Correct Answer: "I will tell him he must calm down or lose privileges."

Two errors sit in one sentence. Telling an escalating client to calm down reads as dismissal, and attaching a loss of privileges turns it into an ultimatum, leaving him only surrender or a fight. Option b is incorrect because open visible hands and extra personal space are textbook de-escalation. Space needs expand under threat, and hands kept in sight remove any suggestion that the student is concealing something. Option c is incorrect because clearing bystanders is one of the first environmental moves. An agitated man performing in front of peers cannot back down without humiliation, so the smaller the audience the better. Option d is incorrect because brief phrasing suits a client whose processing is narrowed by arousal, and listening is often the whole intervention. Letting the client talk gives the student information and gives him the sense of being heard.

Correct Answer: Place a familiar photograph on her door

An old family picture works because visual recognition and remote memory survive long after recent memory and numbers fail. The client identifies her own doorway without needing to read or recall anything new. Option a is incorrect because a room beside the doors invites elopement rather than solving the wandering. Placement near the nursing station allows close observation, while proximity to an exit multiplies the risk of leaving unnoticed. Option b is incorrect because bigger numerals still demand reading and recall of an arbitrary figure she was told once. Enlarged print helps a client with poor vision, not one whose new learning has stopped. Option d is incorrect because hourly repetition places the burden on failing short term recall and turns into quizzing. She will not retain the figure, and the repeated correction leaves her feeling incompetent.

Correct Answer: "When you get angry, have you ever hit anyone or thrown things?"

A history of past violence is the single strongest predictor of future violence, stronger than size, diagnosis, or how angry the client looks right now. The nurse asks about it directly. Option a is incorrect because body size tells the nurse nothing about intent and everything about how a takedown might go. Small clients assault staff regularly, and asking about physique also reads as sizing him up. Option c is incorrect because a diagnostic label carries far weaker predictive weight than behaviour does. Most people with psychiatric diagnoses are never violent, and leading with that question also signals suspicion at the first meeting. Option d is incorrect because inviting him to argue about the involuntary admission hands him a grievance to rehearse. Debating the legitimacy of the commitment escalates a man already feeling powerless and yields no information about danger.

Correct Answer: Vascular neurocognitive disorder

Stepwise decline with plateaus, focal weakness, and executive slowing on a background of hypertension and atrial fibrillation points to infarct related disease. Controlling blood pressure, rhythm, and cholesterol can genuinely change the trajectory here. Option a is incorrect because amyloid disease slides downward smoothly rather than in visible steps, and it opens with recent memory loss. Focal weakness on one side belongs to a stroke, not to plaque and tangle pathology. Option b is incorrect because behaviour and language lead that illness, typically in someone aged forty five to sixty five with preserved memory. Cardiac risk factors and one sided weakness have no place in its usual profile. Option c is incorrect because alpha synuclein disease brings vivid visual hallucinations, parkinsonism, and cognition that swings hour by hour. The stem describes discrete stepwise losses instead, with no hallucinations and no movement disorder reported.

Correct Answer: Explain that symptoms must appear in two or more settings

Diagnosis requires symptoms in at least two settings with several present before age twelve. This boy functions well at home, so the school picture alone cannot support a stimulant prescription today. Option a is incorrect because a controlled stimulant should not start before baseline height, weight, blood pressure, heart rate and cardiac history are obtained. Prescribing on a single setting report skips the diagnosis itself. Option b is incorrect because agreeing that one source suffices confirms an assumption the criteria reject. Standardised rating scales are collected from parent and teacher together, precisely so a single viewpoint cannot drive the decision. Option d is incorrect because sensory screening does belong in a full workup, yet it answers a different question than the one this mother raised. The immediate obstacle is that symptoms appear in only one setting.

Correct Answer: The child and the older adult require reports

Suspected child maltreatment and suspected elder mistreatment both carry a mandatory report. For a competent adult disclosing partner violence, most states leave the choice with her unless a weapon injury or vulnerability applies. Option a is incorrect because sweeping every case into one rule ignores the adult's legal capacity. Reporting her disclosure without consent can raise her danger, and most states do not require it. Option b is incorrect because it leaves out the older adult, whose untreated wounds and poor hygiene suggest neglect. Adult protective services receives that referral in nearly every state. Option c is incorrect because written permission is never a precondition for a mandated report. Good faith reporters have immunity, reporting overrides privacy rules, and failing to report is itself a crime.

Correct Answer: Escorting a client along the walking path

Walking a client on a safe route is a standard, predictable task with clear instructions and no assessment judgment attached. It also meets the need behind wandering, so it fits within the assistant scope. Option a is incorrect because judging whether a family grasped teaching requires evaluation, a step the registered nurse owns. Assistants may reinforce information already taught, yet they cannot decide whether learning actually occurred. Option c is incorrect because screening for acute confusion is assessment, and acute confusion signals a medical emergency needing a licensed judgment. Assistants can report what they observe, but the interpretation stays with the nurse. Option d is incorrect because identifying the trigger behind resistance calls for analysis of pain, fear, and approach. That reasoning sits squarely in the nursing process and cannot be handed to unlicensed staff.

Correct Answer: Anger is a normal emotion needing constructive expression

Anger is a feeling, not an action. This client names the emotion and denies any intent to act on it, so the nurse helps him voice the frustration rather than treating him as dangerous. Option b is incorrect because aggression describes behaviour meant to threaten or injure, and nothing here shows it. Setting limits on a man who is only talking about his anger invites the escalation those limits aim to prevent. Option c is incorrect because violence means the physical acting out of aggression against people or property. Verbal reports of fury with a denial of intent sit far from that end, and summoning backup would humiliate him. Option d is incorrect because passive aggressive expression works indirectly through sarcasm, sulking, or quiet sabotage. This client stated his grievance openly and directly, which is the assertive style staff want to reinforce rather than a hidden one.

Correct Answer: Bruising on a child who cannot yet crawl

Bruises need mobility to happen, so an infant who does not yet move on his own should not have them. Those who do not cruise rarely bruise, which makes this finding abuse until proven otherwise. Option a is incorrect because scraped knees are the ordinary currency of learning to walk. Shin and knee injuries sit over bony points that a toddler lands on dozens of times a day. Option c is incorrect because a forehead bump matches how a mobile toddler falls, face first and forward. Concerning locations are the torso, the ears, and the neck rather than the front of the head. Option d is incorrect because diaper rash is common and usually reflects moisture rather than maltreatment. Neglect would show as an untreated severe rash together with poor hygiene, weight loss, and missed appointments.

Correct Answer: Crisis overwhelms problem solving, so the nurse directs

A person in crisis has temporarily lost the capacity to generate solutions, so the nurse takes a directive role, supplies information, and offers concrete choices, returning decisions to the client as functioning recovers. Option b is incorrect because direction in crisis is temporary and deliberately minimal. The nurse uses the least amount needed and hands autonomy back as soon as the client can weigh options again, which prevents dependence. Option c is incorrect because open ended questions remain a mainstay of psychiatric interviewing and are used constantly elsewhere. What changes in crisis is the balance, with more structure added while the client's own problem solving is offline. Option d is incorrect because goal setting never displaces the safety screen. Suicidal and homicidal ideation are assessed first, and only after that does the nurse move on to naming the problem and planning steps.